Office of Nutrition Services

WV WIC New Client Inquiry Form


July 24, 2008

PLEASE TELL US ABOUT YOURSELF

* indicates required field(s)

First Name*
 Last Name*

Date of Birth
 If Pregnant, Due Date

Have you ever received WIC benefits in WV? 

Are you breastfeeding?


PLEASE PROVIDE YOUR CONTACT INFORMATION

Address

City

Select County
    State
    		   Zip
   

Email Address

Check this box if you would like to receive an email copy of this request

Phone Numbers:

Home
 Work

Cell
 Message

Best time to reach you?

PLEASE TELL US ABOUT YOUR HOUSEHOLD

How many people reside in your household? 

Please List Children Under 5 Years of Age
 
    Child's First Name Child's Last Name Child Date of Birth
1.
2.
3.
4.
5.

PLEASE PROVIDE YOUR INCOME INFORMATION

Gross Monthly Income 

Do you currently receive?   

TANF    Food Stamps    Medical Card


Question(s) about WIC